Chapters Transcript Video Case Review- Truncal and Perforator Vein Approaches Back to Symposium So I'm Dana Dunleavy. I'm from Buffalo Interventional Radilogy, and um since the surgeon starts at 9:30, I get yelled at by all my surgical colleagues that I start too early, so I get really fussy if incision time's not at 7:30 and so um. The team wasn't used to that when I joined the surgical practice, but. I'm gonna go through the simple stuff so kinda say you know I'm the simple farmer in the country and I am outside of Buffalo in a multidisciplinary practice, but I also serve as the chair of the small and rural practice committee and and serve as a director of some small hospitals too, which is very rewarding as well to see how we can help there. So just kind of going over different practices and we won't talk about it much but if anyone wants to reach out later I think I've been in all different sites of service and um some people feel very confined depending on their situation right? you have Doctor Lesni who is hospital based and then you have me who's been predominantly office based and now I. You know, take my deep venous cases to the ASC and so really they all have different things and, and it was very helpful right last night to have the the coding updates because there's a a massive difference this year than last year and it's, it's hard to keep up with all of those changes if you're trying to do clinical care as your focus but um when we were talking last night about some rewarding things you know superficial venous disease sometimes gets. Brushed under because it's it's not the most challenging thing that we do but on the other hand they are some of the healthiest patients potentially right that can come back and thank you for years and years that you've you've changed their life and improved other things about their quality. So just looking at, you know, a case of a 62 year old, um, I think one of the things that can be challenging is whether someone's already touched this and done an incomplete job and so as Doctor Murphy was saying, right, you can assess whether you get up to the junction and how far down you wanna go, but the longer the treatment segment you can expect, the longer the benefit, the more durable the benefit. And so in a situation like this where the person had a, a, basically this is a practice where they they turn the laser on and they turn it back off and then they bill for it and so you have uh patients that look like this so you, you, you have a sonographer which if you just sent them anywhere they might just say it's closed and and call it a day, right? But if you follow the vein down you see it's still 10 millimeters in the proximal thigh 9 in the mid-thigh. You know you have well over 34 seconds reflux anywhere you look as you follow down into the calf, you have these, these massive varices, right? And, and you can see depending on the image, right, you have flow going antegrade retrograde, you have thrombophlebitis in different segments, so this is a patient that. Basically after treatment continued to go to the emergency department because she would get these episodes of thrombophlebitis and then they actually put her on anticoagulation, so a whole bunch of of negative things, right, that we can prevent. Here is a a similar case right that that's even more difficult to consider right is is there the closure is in the mid thigh so now you have varices coming off the proximal segment and the mid segment and then you have this occlusion in between and so sometimes we can find well simply uh um. Vent closed catheter itself, right, can just cross right because it is steerable. You can put glide wire through and do that, um, or you can use something like either enclose above and below or you could use a maven above and vent close below. So I think that, um, some of our old teaching, right, if we, we have to go to ligation or just, you know, do sclero, which we know the closure rates are gonna be lower, um, here you have an option. Just as, as was mentioned, right, is, is you can always do something with this and again. As we, we discussed before, rather than having two different sheath size and 2 different catheter lengths, you know, you just have one thing that works every time. So as we follow this down, right, you can see pretty, pretty substantial varices that go down into the thigh and the calf and been symptomatic and had multiple hospitalizations so, um, Doctor Murphy nicely covered the catheter and I'll go over it a little bit more later, but. Um, here is an option right where just, you know, wireless you can steer it through both the subfascial and epifascial segments, get to where you need to do and, and treat the whole length of the vein and, um, really makes it quite easy as opposed to other things we've done where you can try to use multiple different wires. The Maven, um, as noted, obviously is designed for perforators, uh, but a lot of practices that that get comfortable with it realize they can also use it for cases like this. There's really no vein you can't treat with it, and I think that, um, that makes it nice, right, especially if you're gonna combine it with something else. So here's a 44-year-old male, uh, healed wounds, not, not as healthy, right? So a VCSS of 19, a CEPA 5. Um, kinda mentioned, you know, as Kim was talking about last night, really incredible job in terms of awareness and how we, we identify these patients and make sure they're getting their care for diabetes and PAD, and, uh, I mentioned the, the PDN or DPN at the end, right? So that's different terms we have for painful diabetic neuropathy or diabetic polyneuropathy. And in my region since I'm a strange guy and I, I do neurostimulation for those patients, there's actually been a helpful way since I don't do PAD that I get these patients to the people in the region that do and many of them are just uncared for so I think that um there's a great opportunity uh for multidisciplinary collaboration on these patients and then we look at the. You know, surgical history, you say L3S1 laminectomy and fusion, and, and we've had some really interesting talks, right? If you really understand the approach that people take for lumbosacral fusion, you start to understand why a lot of these patients have deep venous disease too, right? What are they doing during that case? Are they actually injuring the common iliac vein? Are they retracting the iliac vein for a long time? There's multiple reasons why they'll come back, you know, with, with deep venous disease that we have to manage. And so here you see the the perforator and the reflux, obviously this does take some time for the sonographers as well. This was a case that um. One of the people in my practice did and I think it just helps as Doctor Murphy mentioned that the approach is very important so if you wanna have a high closure rate, you have to. Get pretty good at at what your approach is going to be, right? You, you actually want to get down, you know, to the fascia or beyond the fascia and and so this was kind of the easy way out but has a lower closure rate right? if you're gonna just treat essentially the varen as opposed to the perforator, you're not gonna do as well it's, it's safe and it's easy, but it's, it's not as successful so. Another, and, and I think uh we covered this, but essentially just note that the ablation length as opposed to 10 centimeters or 2.5 centimeters is half a centimeter and you can do that kind of rapid fire 6 cycles, pull back 6 cycles, pull back 4 cycles is is kind of the the most common approach. And so you know in a case like this also uh once you nicely cause closure, you can be a little bit more generous with your sclero than you would be otherwise if you're right next to a perforator so it can be really uh helpful to combine in that way, and here's just a different case with a slightly different approach so. You know, one of the things that is helpful for both physicians and sonographers is, you know, we can be pretty standardized with a GSV or accessory or SSV, but perforators don't really listen to us, right? They're rungs on a ladder, but they come off on any, any given angle and so identifying what is the best angle for you to have the highest safety and highest closure is really important. So increased closure rate, decreased DVT is important in that. And so I usually just kind of assess right that I think sometimes people don't do wonderful with superficial disease because it's below them, and so I think it can be really helpful to just like everything we do really master it. From the Maven and Venlo standpoint, you know, whether we're in a, a big hospital or a tiny place, everyone would really like to reduce how many products they have. So having a single sheath, single catheter, tech can put it on the table and just know you're gonna use it every time is, is really wonderful and, and if it turns out that it needs to be a shorter segment than they thought, it still works out, so that can be very helpful. And again that can be super nice whether it's, it's challenging anatomy or simple anatomy works every time. Thank you very much. Published Created by
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